肝移植术后胆道非吻合口狭窄的诊治

Diagnosis and management of non-anastomotic biliary stricture after liver transplantation

目的 探讨肝移植术后胆道非吻合口狭窄（NABS）的诊治流程.方法 回顾性分析近10年来我中心肝移植术后发生胆道NABS患者的临床资料,比较NABS的各种诊断和治疗方法,探讨其最佳诊治流程.结果 本中心403例次肝移植患者NABS总体发生率3.2％（13/403）,其中心脏死亡供体捐献（DCD）NABS发生率4.16％ （2/48）,两者比较差异无统计学意义（P＞0.05）.NABS主要表现为胆红素、胆道酶谱升高及反复发作的胆管炎,与对照组（n=20）比较均差异显著（P＜0.01）.全部患者经胆道造影确诊,并据此将NABS分为3型：围肝门部狭窄（Ⅰ型,4例）;肝门部＋肝内胆管狭窄（Ⅱ型,7例）;肝内胆管多发狭窄（Ⅲ型,2例）.本组NABS患者的治疗主要包括介入微创、胆肠吻合、再次移植3种方法.Ⅰ型患者均通过介入微创和胆肠吻合治愈,但有44.4％ （4/9）的Ⅱ型和Ⅲ型患者需要再移植治疗.再移植后死亡1例,余12例疗效满意,总有效率92.3％（12/13）,治疗后随访12例患者胆红素及胆道酶谱均明显下降（P＜0.05）.结论 胆道非吻合口狭窄是肝移植术后一种常见的胆道并发症,胆道造影是诊断的金标准.根据胆道造影显现的狭窄类型,遵循从简单到复杂的流程,选择介入微创、胆-肠吻合或再移植手术.Ⅰ型患者相对处理简单,预后最佳,Ⅱ型及Ⅲ型患者若介入微创治疗无效,应及时再次移植.

Objective To study the diagnosis and treatment of non-anastomotic biliary stricture （NABS） after liver transplantation.Methods The clinical data of 403 patients who underwent liver transplantation in the past 10 years in our department were analyzed retrospectively,compared different methods to find out the most appropriate method in the diagnosis and management of NABS.Results NABS occurred in 13 out of 403 patients （3.2%）,almost the same incidence as in patients who received DCD donor livers （4.16%,2/48）.The clinical signs of NABS were frequent cholangitis and high TBil,r-GT and AKP （P 〈0.01）.All these cases were finally diagnosed by cholangiography and they could be classified into 3 types：hepatic bile duct stricture （4 patients,type Ⅰ）,multiple extrahepatic and intrahepatic biliary strictures （7 patients,type Ⅱ）,intrahepatic biliary strictures （2 patients,type Ⅲ）.NABS were mainly treated by interventional therapy,Roux-en-Y anastomosis and retransplantation in our centre.All type Ⅰ patients were successfully managed with interventional therapy/ERCP and Roux-en-Y anastomosis,but 44.4% （4/9） of type Ⅱ and Ⅲ patients required retransplantation.The TBIL,r-GT and AKP decreased significantly in 12 patients （P 〈 0.05） and the total curative rate of NABS was 92.3% （12/13） with one patient who died after retransplantation.Conclusions Cholangiography was an effective way to diagnose NABS which is common among patients after liver transplantation.Interventional therapy/ERCP,Roux-en-Y anastomosis and retransplantation were our 3 ways to treat this problem.We proceeded from easy to difficult and chose a suitable way to deal with NABS according to the different types of biliary stricture from cholangiography.Type Ⅰ patients had much better prognosis than Type Ⅱ and Ⅲ patients who should receive retransplantation if interventional therapy/ERCP failed.